Medication errors involving parenteral nutrition preparations and concentrated electrolytes in a pediatric hospital:...

Parenteral nutrition and concentrated electrolytes are associated with medication errors in pediatrics; however, a systems-based understanding of these errors is lacking. We aimed to describe the errors, contributing factors, and proposed defenses related to these medications in pediatrics.

The study analyzed self-reported medication safety incidents at a pediatric university hospital between 2018 and 2020, focusing on parenteral nutrition and concentrated electrolytes. The reports were investigated through qualitative content analysis, and the results were quantified in frequencies and percentages. Consequently, the Institute for Safe Medication Practices' Hierarchy of Effectiveness of Risk-Reduction Strategies was used to categorize the proposed safety defenses. The analysis used a systems approach to medication risk management, guided by the theory of human error.

In total, 404 medication errors, 627 contributing factors, and 386 proposed defenses were identified within the study sample (n = 279 incident reports). Most errors occurred during the administration (54%) and preparation (25%) phases. Common issues included wrong dose (15%), wrong infusion rate (11%), and incorrectly prepared medicine (18%). Contributing factors were often linked to workload and resources (22%) and employee-related factors (21%). Most proposed defenses were classified as low leverage (71%), with the smallest portion at the highest leverage (6%).

Errors often occur during preparation and administration, primarily because of the complexity of individualized dosing. Contributing factors include high workload, limited resources, and employee-related factors. Hospitals should prioritize implementing systems-based, technology-driven defenses over person-focused strategies. Future research is essential for developing and evaluating child-specific defenses.